MEDICARE: MRS. VICKI HEDGES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1699142729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VICKI HEDGES

Provider Business Mailing Address
First Line	:	500 FAIRWAY DR
Second Line	:	SUITE 102
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33441-1814
Country	:	US
Telephone Number	:	888-880-9270
Fax Number	:

Provider Business Practice Location Address
First Line	:	4030 WAKE FOREST RD
Second Line	:	STE 349
City	:	RALEIGH
State	:	NC
Zip	:	27609-6800
Country	:	US
Telephone Number	:	336-480-6676
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2015
Last Update Date	:	08/24/2015

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